[Remote] Pharmacy Resolution Specialist
Note: The job is a remote job and is open to candidates in USA. RemoteHunter is a diversified national entity that supports 28 million members through its Medical Management/Health Services team. The Pharmacy Resolution Specialist role involves managing pharmacy-related inquiries and resolutions, ensuring compliance with regulatory standards while providing exceptional customer service.
Responsibilities
- Receive and respond to calls from members, provider/physician offices, and pharmacies
- Make outbound calls and enter pharmacy overrides based on approved guidelines and clinical pharmacist approvals
- Handle inquiries regarding benefits including prior authorization requests
- Offer options such as submitting prior authorization requests
- Research issues thoroughly and resolve them using appropriate reference materials within turnaround time and quality standards
- Log, track, resolve, and respond to inquiries and complaints following regulatory, CMS, and corporate guidelines
- Maintain expert knowledge of pharmacy benefits, formularies, and CMS regulations relevant to the position
- Interpret pharmacy and medical benefits accurately
- Conduct inbound and outbound calls to provide resolution on claims, including additional information requests and medication updates
- Initiate and provide status updates on prior authorization, coverage determination, appeal, and redetermination calls
- Ensure outstanding attention to detail
- Identify root cause issues to promote enterprise solutions and communicate findings for first call resolution
- Assist with special projects as assigned
- Perform other duties as assigned
- Comply with all policies and standards
Skills
- High School Diploma or GED
- Minimum 1 year of job-specific call center or customer service experience
Benefits
- Health insurance
- 401K and stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible work options including remote, hybrid, field, or office schedules
Company Overview